Last reviewed: November 2017
Last updated: November  2017

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • asymptomatic
  • pain (peripheral)
  • loss of sensation (peripheral)
  • dysaesthesia (peripheral)
  • reduced or absent ankle reflexes (peripheral)
  • painless injuries (peripheral)
  • resting tachycardia (autonomic)
  • impaired heart rate variability (autonomic)
  • urinary frequency, urgency, nocturia, incontinence, hesitancy, weak stream, or retention (autonomic)
  • erectile dysfunction (autonomic)
  • decreased sexual desire and increased pain during intercourse (autonomic)
  • orthostatic hypotension (autonomic)

Other diagnostic factors

  • constipation (autonomic)
  • faecal incontinence (autonomic)
  • anhidrosis, heat intolerance, dry skin, or hyperhidrosis (autonomic)
  • hypoglycaemia unawareness (autonomic)
  • weakness (peripheral)
  • hx of recent falls (peripheral)
  • gait ataxia (peripheral)
  • nausea, postprandial vomiting, bloating, loss of appetite, early satiety (autonomic)
  • heartburn and dysphagia for solids (autonomic)
  • profuse and watery diarrhoea (autonomic)
  • specific mononeuropathy (peripheral)
  • cranial neuropathy (peripheral)
  • pain over lower thoracic or abdominal wall (peripheral)
  • thigh muscle atrophy, pain, and weakness (peripheral)

Risk factors

  • poorly controlled hyperglycaemia
  • prolonged duration of diabetes
  • older age (e.g., >70 years)
  • tall stature
  • hypertension
  • dyslipidaemia with elevated triglycerides
  • co-existence of multiple CVD risk factors (type 2 diabetes)
  • obesity
  • immune dysregulation
  • smoking

Diagnostic investigations

1st investigations to order

  • corneal confocal microscopy
  • clinical diagnosis
  • fasting blood glucose
  • HbA1c
  • serum TSH
  • serum vitamin B12
  • electrolytes, urea, creatinine
  • serum lipid profile
  • LFTs
  • FBC and erythrocyte sedimentation rate
  • serum/urine immunoelectrophoresis
Full details

Investigations to consider

  • oral glucose tolerance test
  • nerve conduction studies (nerve conduction velocity, NCV)
  • electromyography (EMG)
  • quantitative sensory testing (QST)
  • skin biopsy
  • cardiovascular reflex testing
  • heart rate variability (HRV)
  • gastric emptying studies
  • gastroduodenoscopy
  • surface electrogastrography
  • barium meal
  • GI manometry
  • hydrogen breath tests
  • gastric ultrasonography
  • gastric MRI
  • anorectal manometry
  • faecal fat
  • d-xylose test
  • urine culture
  • cystometry, voiding cystometrogram
  • post-void urinary tract ultrasound
  • video-urodynamics
  • measurement of nocturnal penile tumescence and of penile and brachial BP
  • serum LH, testosterone, free testosterone, prolactin
  • sudomotor function tests
  • scintigraphic studies
  • assessment of sympathetic muscle activity
  • cardiac vagal baroreflex sensitivity testing
  • 24-hour BP profile
  • microneurography
Full details

Treatment algorithm

Contributors

Authors VIEW ALL

Professor of Medicine

Organizational Official for the Human Research Protection Program

Weill Cornell Medicine - Qatar

Doha

Qatar

Disclosures

RAM is on speaker panels for Eli Lilly, Novo Nordisk, and Pfizer; he is on advisory boards for Novo Nordisk and Pfizer. RAM is an author of a number of references cited in this monograph.

Speciality Registrar in Diabetes & Endocrinology and General Internal Medicine

University of Manchester

Manchester

UK

Disclosures

UA serves on advisory boards for Eli Lilly.

SpR Diabetes and Endocrinology

Diabetes and Endocrinology

University of Manchester

Manchester

UK

Disclosures

SA declares that she has no competing interests.

Dr Rayaz Malik, Dr Uazman Alam, and Dr Shazli Azmi would like to gratefully acknowledge Dr Rodica Pop-Busui and Dr Eva Feldman, the previous contributors to this monograph. RPB declares that she has received speaking honoraria from Pfizer and research support from Amylin Pharmaceuticals; National Institutes of Health/National Heart, Lung, and Blood Institute; National Institute of Health/National Institute of Diabetes and Digestive and Kidney Diseases; American Diabetes Association; and Juvenile Diabetes Research Foundation. RPB is an author of several references cited in this monograph. EF is an author of a number of references cited in this monograph.

Peer reviewers VIEW ALL

Clinical Professor

Department of Medicine

Mount Sinai School of Medicine

New York

NY

Disclosures

ZTB declares that he has no competing interests.

Assistant Professor of Medicine

Harvard Medical School

Division of Endocrinology

Diabetes and Hypertension

Brigham and Women's Hospital

Boston

MA

Disclosures

RKG has received consultant fees from Aventis and Novartis, and speaker fees from Novartis.

Consultant and Honorary Senior Lecturer

Tameside General Hospital

Diabetes Centre

Ashton Under Lyne

Lancashire

UK

Disclosures

EJ has received funding for conferences and lectures from Pfizer and Boehringer Ingelheim.

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